Candidate Information Form

Thank you for your interest in Up With Women's coaching program! This program has helped hundreds of women in Canada over the past 10 years and we are excited to consider you as the newest addition to the Up With Women family!

This survey will take approximately 5-10 minutes to complete and is incredibly important to make sure that we are helping you as much as we can! It must be completed in order to receive Up With Women's coaching services.

Several questions are optional so please answer these in as much detail and honesty as you feel comfortable with, however some questions are required for submission (indicated by red star). If you are not sure how to answer a question, please ask your program manager for help during your intake interview or email her or Althea ( following your intake interview.
Candidate privacy is extremely important to us and the information you provide in this survey will be kept confidential by Up With Women.

Basic Information

Numbers only (e.g. 4161112233)

Numbers only (e.g. 4161112233)
Family Information

"Single" if in a relationship but not domestic partnership/married or if separated, divorced, or widowed

0 if you do not have children

Count child as living with you if you have 50% custody or higher, do not count if less than 50% custody
Education Information

Check "some college/university" if you dropped out of or are currently enrolled in college/university
Ethnic Information

Personal Information

Neurodevelopmental differences include Autism, ADHD, etc.  

Coaching Preferences

E.g. Work night shifts so never available in evenings

Additional Information